2015 protocol update with narration
TRANSCRIPT
2015
Southwest Ohio
pre hospital Protocol
UpdateAcademy of Medicine of Cincinnati
Protocol Subcommittee
Hamilton Lempert, MD FACEP CEDC
Chairman
Protocol Committee
Mary Ahlers, RN, CP, NRP
Mark Baird, EMT-P
Justin Benoit, MD
Larry Bennett, Esq
Mike Bilkasley, EMT-P, L.O., L.Ped
Mike Bohanske, MD
Troy Bonfield
Todd Burwinkel EMT-P
Dustin J. Calhoun, MD
Steve Coley, NREMT-P
Kenneth Crank, NREMT-P
Roseann Cyriac, MD
Dave Derbyshire, NREMT-P
Tom Dietz, NREMT-P
Pamela Erpenbeck RN, NREMT-P
Hamilton Lempert, MD FACEP Chairman
Greg Faris, MD
Kirk Fisher, RN, NRP
Paul Gallo, EMT-P
Ryan Gerecht, MD
Marilyn Goin EMT-P
Constance Gong, MD
Bob Herrlinger RN, EMT-P
Randall Johann, FP-C, EMT-P
Andy Kalb, EMT-P
Dave Kemper EMT-P
Ashley Larrimore, MD
Andrew Latimer, MD
Dustin LeBlanc, MD
Donald Locasto, MD
Walt Lubbers, MD
Daniel Mack, NREMT-P
Jason McMullan, MD
Will Mueller, EMT-P
Mike Moyer, PhD, MS, EMT-P
Bob Murray, EMT-P
Mel Otten, MD
Todd Owens, EMT-P
Joel Pranikoff, MD
Andrew Rice, MS, NREMT-P
Hamilton Schwartz, MD
Joe Stoffolano, NREMT-P
Mike Steuerwald, MD
Ferenc Tirkala, EMT-P
Jonathan Van Zile, MD
Paria Wilson, MD
Introduction
• Many new protocols
• Administrative
• Symptom Based
• Medical
• Surgical
• Pediatric
• Procedures
• Medication list
• Drug License
Administrative
• A108 – Use of EMS units as Transport Units
• New Protocol
• Some departments do this
• Must have written orders for treatment outside of
protocols
• Can not operate out of scope of practice
• May need additional personnel
Administrative
• A109 Advanced EMT
• New Protocol
• Allows EMT – A to function at their level within their
scope of practice
• Lays out a state mandated list of procedures and
medications that EMT – A’s can use
Symptom Based
• SB205 Hypotension/Shock
• Brand new Protocol
• Covers many different types of shock
• Hypovolemia
• Cardiogenic
• Obstructive
• Distributive
• Sepsis
• Push Dose EPI
Push Dose EPI
• 1 ml of 1:10,000 epi – cardiac epi
• Mix with 9 ml of Normal Saline
• Administer 1 ml every 1-2 minutes as needed
• Takes the place of Dopamine
Cardiac
• C302 Bradycardia
• Moved Versed for External pacing to be right next to
external pacing
• Many of the protocols have such small grammatical
and organizational changes
• This one is the most significant
Medical
• M411 – Toxicological
• Removed Charcoal
• Rarely used – no longer recommended
• Can aspirate and have bad outcome
• Cyanide
• Treatment should occur when both of the following are
present
• Decreased Level of Consciousness
• Hypotension
• There are no absolute contraindications
• Treatment may temporarily turn the victim’s skin orange
Medical
• M411 – Toxicological
• Naloxone
• EMT may now give IN or Auto Injector
• Intranasal (IN)
• Do not use more than 1 ml of medication per nostril (0.2 to
0.3 is the ideal volume). If a higher volume is required, apply
it in two separate doses allowing a few minutes between for
the previous dose to absorb.
• Always deliver half the medication dose up each nostril. This
doubles the available mucosal surface area (over a single
nostril) for drug absorption and increases rate and amount of
absorption.
Medical
• M411 – Toxicological
• Naloxone
• Auto Injector
• Follow manufacturer recommendations
• The FDA has approved Evzio (naloxone) a $600 (as of
2014) naloxone auto-injector for treating suspected opioid
overdose, analogous to an epinephrine pen for
analphylaxis. Evzio comes in a kit with two 0.4 mg auto-
injectors and a “trainer” device that also has voice
guidance. The standard 0.4 mg injectable dose of
naloxone, which can be given intranasally, costs about $20
Medical
• M416 – OTC Meds
• New Protocol
• The patient expressly requests treatment for a minor
medical concern by a specific over-the-counter (OTC)
medication.
• No sign or symptom of a significant medical condition
exists.
• The paramedic has access to the official
manufacturer’s list of indications, contraindications,
and administration instructions.
Medical
• M416 – OTC Meds
• This protocol is not intended for use with patients being
transported to the hospital, but instead for patients seeking
care at “special events” where paramedics are stationed or
for emergency personnel on critical scene assignments.
• We do not need to put OTC meds on our drug license
Surgical
• S500 Hemorrhagic shock
• Immobilize per T704 added
Surgical
• S501 Head or Spinal Trauma
• Added lots of things to comply with national brain injury
guidelines
• Changed protocol to 95% sat
• Normal Ventilation
• Maintain RR 14-16
• End tidal CO2 35-40
Surgical
• S501 Head or Spinal Trauma
• If pupils >1mm difference and comotose
• Hyperventilate to end tidal CO2 of 30
• Consider 3% saline
• Stop if pupils normalize
• Decided not to do mannitol for variety of reasons
Surgical
• S503 Imminent Delivery (Child Birth)• Changed Viability to 24 weeks
• Gave more detailed instructions on delivery
• Where to clamp umbilical cord
• Meconium staining
• infants with meconium-stained amniotic fluid should no longer routinely receive intrapartum suctioning. If the newborn is vigorous, defined as having strong respiratory efforts, good muscle tone, and a heart rate greater than 100 beats per minute, there is no evidence that tracheal suctioning is necessary. Injury to the vocal cords is more likely to occur when attempting to intubate a vigorous newborn.
• If meconium is present and the newborn is depressed, refer to P600 Pediatric Newborn Resuscitation.
• Take mom and baby to same hospital
Surgical
• S506 Tranexamic Acid (TXA)
• Brand new protocol
• Not yet for Peds
• Active research and you may see some other
protocols out there with AirCare or other higher level
care providers
• Presentations on Protocol Website
Surgical
Tranexamic acid (TXA) Checklist
Administration of TXA is indicated if all of the following criteria are present
1) Age 16
2) Evidence of significant blunt or penetrating traumatic injury
(MVC with ejection, rollover MVC, fall > 20 ft, pedestrian struck, penetrating injury to head,
neck, torso, etc.)
3) Evidence of or concern for severe internal or external hemorrhage
(bleeding requiring a tourniquet, unstable pelvic fracture, two or more proximal long-bone
fractures,
flail chest etc.)
4) Sustained Systolic BP < 90mmHg (or < 100mmHg if older than 55 yo)
5) Sustained heart rate > 110 bpm
6) Time since the initial injury is known to be < 3 hours
To administer TXA: Mix 1g of TXA in 100ml of 0.9% Normal Saline or Lactated Ringers & infuse over 10
minutes IV or IO. (If given as an IV push, may cause hypotension) Use dedicated IV/IO line if possible and Do NOT
administer in the same IV or IO line as blood products, factor VIIa, or Penicillin
Pediatric
• P615 Pediatric Submersion Injury
• Brand new protocol
• Ice visible on water
Pediatric
• P615 Pediatric Submersion Injury
• If there are obvious signs of ice on the water,
ensure ALS back-up and proceed with the cardiac
arrest protocols P601 or P602 depending on whether
their initial presentation is VF/VT or PEA/asystole.
• Maintain airway and administer oxygen.
• Initiate transport to Cincinnati Children’s Burnet Campus,
which is capable of performing pediatric extracorporeal
membrane oxygenation (ECMO).
• Notify Cincinnati Children’s.
Pediatric
• P615 Pediatric Submersion Injury
• If there are NO obvious signs of ice, and the patient
has been submerged for 30 minutes or longer, the
evidence suggests the patient is unlikely to survive.
Ensure ALS back-up and proceed with the cardiac
arrest protocols P601 or P602 depending on whether
their initial presentation is VF/VT or PEA/asystole.
Contact medical control to discuss CPR limits. If
patient is transported, transport to the closest
emergency department while performing CPR.
Pediatric
• P615 Pediatric Submersion Injury
• If there are NO signs of ice, and the patient has been
submerged for less than 30 minutes or the time is
unknown, ensure ALS back-up and proceed with the
cardiac arrest protocols P601 or P602 depending on
whether their initial presentation is VF/VT or
PEA/asystole). Transport to the closest emergency
department while performing CPR. Notify receiving
hospital.
Procedures
• T704 Spinal Immobilization
• Major rewrite
• Strengthened statement re who to put in immobilization -
only
• Altered mental status (anything less than a GCS of 15 and
normal alertness)
• Suspicion of intoxication (any substance, including pain
medications)
• Distraction (either painful distracting injury or psychosocial
distraction)
• Midline spinal tenderness (careful palpation exam required)
• Focal neurologic deficit (anything less than a full and
symmetric motor and sensory exam in all limbs)
Procedures
• T705 Airway
• Change “rescue airway” to “supraglottic airway”
• Added to basic technique
• Immobilization of a patient with a compromised airway
using a c-collar and backboard should only be considered
/ performed in the trauma patient. Utilizing the reverse
Trendelenburg position by elevating the head of the cot /
backboard 20 degrees has shown benefits to both
patients with a compromised airway and during intubation
by facilitating better laryngeal exposure during direct
laryngoscopy and reducing atelectatic collapse of the
posterior lungs.
Procedures
• T705 Airway
• Defined basic airway failure
• (chest rise and/or audible bilateral breath sounds),
• The decision to utilize orotracheal intubation and/or a
Supraglottic Airway (King Airway etc) as the preferred
advanced airway shall be the decision of the EMS service
and its medical director. Regular training in each airway
skill shall be conducted and documented and available for
review during the Academy of Medicine Compliance and
Inspection Committee Site Visit Review.
Procedures
• T705 Airway
• Removed old reference to nasal intubation
• No more than 2 attempts at intubation
• Question regarding S502 burn management
• Recommends intubation if patient has
• Respiratory distress
• Unconscious
• Re-did flow diagram
Procedures
Procedures
• T706 Orotracheal intubation
• Removed “hyper” oxygenate
• Pre-oxygenate the patient if time allows, studies have
shown that use of oxygen by nasal cannula at 15 lpm
during intubation and insertion of an SGA aid in the pre
oxygenation of the patient. Pre oxygenation using a nasal
cannula with BVM ventilations also increases the
oropharyngeal FiO2 (fraction of inspired oxygen).
• Added not to stop chest compressions
• Added 20 degree head up
• Removed cricoid pressure, left in BURP
Procedures
• T710 Hemorrhage Control
• New Protocol
• Replaces Tourniquet protocol
• Tools to control hemorrhage
• Tourniquet
• Wound packing
• Hemostatic Guaze
• TXA
Medications
• Added
• Hypertonic Saline
• Evzio
• Lactated Ringers
• Tranexamic Acid (TXA)
Medications
• Removed
• Lasix
• M404 CHF
• Dopamine
• P609Anaphylaxis
• M411 toxicology
• M409 Anaphylaxix
• M401 Cardiogenic Shock
• M400 Acute coronary syndrome
• C307 ROSC
• C302 Bradycardia
Medications
• Not needed to be added
• Hemostatic Guaze
• Over the counter medications
• New Drug list for EMT Basic
• Asprin
• EpiPen
• Narcan – Evzio
• Oxygen
• Duodote
• Sterile water for irrigation
Drug License
• Current drug license extended until 3-31-15
• Go to State Pharmacy Board website to renew
• Upload 2015 protocols, drug list, personnel list
• Protocol and drug list must be notarized
• Instructions on State website and will get letter soon
• Call Todd Owens of Reading with any questions
• 733-5537
Final Approval
• 2015 Protocols posted on Academy of Medicine
Website on October 1st. academyofmedicine.org
• Open for comments until December 1st
• Please find all of our typo’s and mistakes
• Send your comments to Dr. Lempert
• Updated Protocols will be posted on Academy of
Medicine website the last week of December for
implementation January 1st, 2015